My health for life will help people at high risk of developing chronic conditions such as heart disease, stroke and type 2 diabetes make healthy lifestyle changes.

The steps in this recipe show how to identify patients meeting all or most of the eligibility criteria. Further information and resources are available here: https://www.myhealthforlife.com.au/

Target:

To identify all patients with no current diagnosis of diabetes, Heart Failure, CVD or chronic kidney disease who are eligible to be referred to the ‘My Health For Life’ program and are at high risk of a cardiovascular event in the next five years based on the absolute CV risk assessment.

CAT Starting Point:

CAT Open - CAT4 view (all reports) loaded

Population Extract Loaded and Extract Pane “Hidden”

Filter Pane open and under the ‘General’ tab ‘Active Patients’ (3x <2 years) selected (this step can be omitted if you want to search for all patients).

We provide other recipes showing how to find patients based on a single eligibility criteria on our My Health For Life recipe page here: My Health For Life Recipes

This recipe can be combined with the other recipes, for example you could use the recipe for patients with familial hypercholesterolaemia and then find who out of that group is at high risk of a CV event risk.

CAT Start screen

RECIPE Steps Filters:

In the Start Age box type 45 or 18 if looking for indigenous patients to show patients older than 45.

If you want to search for indigenous patients older than 18 you will have to also apply the ‘Indigenous’ filter on the ‘Ethnicity’ tab. See here for full details: Ethnicity Filter

OPTIONAL: In the "General" filter tab click on 'Active (3x in 2yrs)' - this will only show those patients with at least 3 visits in the last 2 years

Click on "Conditions" tab under Diabetes select “No”

Select "No" for Heart Failure

Select “No” for all conditions listed under the CVD group

Select “No” for “Chronic Renal Failure”

We have now created a filter to find patients older than 45 (or indigenous patients older than 18), with no diagnosis of diabetes, Heart Failure, CVD or chronic renal disease.

This will most likely produce a large list of patients, in this case more than 3000 patients.

To find patients at high risk of a CV event we will use the CV Event risk report in CAT4 - full details can be found here: CV (Cardiovascular) Event Risk

Limitations:

The CV Event risk report uses blood pressure and lipid results regardless of when the result was entered/taken. The most recent result will be used to calculate the risk. The reason behind this process is that a patient who was at high risk some time ago and doesn't have any recent results should be reviewed.

CV Event Risk report

To find the patients at high risk of a CV event in the next five years, click on the CV Even Risk report tab and select the 16- >=30% ranges, then click on 'Export'

This will show a list of all patients at 16% or higher risk of a CV event in the next five years, with the selected demographic filter (45+ or indigenous and 18+) and with no diagnosis of heart disease, diabetes or chronic kidney disease.

Incomplete CV Event risk data

The second tab of the report shows the patients with missing data items:

Active patients with more than three visits should have most of the data items completed and this report will show if this is the case or not. No CV event risk can be calculated if the data is incomplete.